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Communicating with people with acquired communication disorders

Definitions

Aphasia or dysphasia

Aphasia or dysphasia (the terms can be used interchangeably) is an acquired communication disorder that impairs a person's ability to process language. It does not affect intelligence but does affect how someone uses language. A neurological condition or acquired brain injury can affect the formulation, expression and/or understanding of language in both written and spoken form (González‐Fernández et al. [109]). Aphasia may be temporary or permanent. A patient with receptive aphasia has difficulty understanding spoken or written language. Conversely, expressive aphasia is typically characterized by partial loss of the ability to produce spoken or written language. Someone may have a solely receptive or expressive aphasia but more commonly they will have a combination of the two; they may also have additional cognitive difficulties.

Dysarthria

Dysarthria is a motor speech disorder. It occurs when weakness, dyscoordination and/or sensory loss affect muscle function in one or more of the five subsystems of speech (i.e. respiration, articulation, phonation, resonance and prosody (González‐Fernández et al. [109]). This can result in speech that is low in volume, slurred, nasal and/or flat.

Acquired dyspraxia

Acquired dyspraxia of speech results in difficulty planning and/or co‐ordinating articulatory movements due to damage to the brain from a head trauma, stroke or brain tumour. The person is aware of how their speech should sound and their verbal expression may be hesitant with sound substitutions, for example saying ‘tup of tea’ instead of ‘cup of tea’.

Dysphonia

Dysphonia is a voice disorder and may be related to disordered laryngeal, respiratory and vocal tract function. It reflects structural, neurological, psychological and behavioural problems as well as systemic conditions (Mathieson [167]).

Cognitive communication disorder

Cognitive communication disorder affects the link between cognition and its influence on verbal and non‐verbal communication, reading and writing. Cognitive deficits can affect attention, memory, organization, processing and executive function, which in turn affect communication.

Related theory

Many areas of the brain are involved with language and cognitive processing, and the complex relationship between the brain's structure and functions is still not fully understood. The brain can be divided into four primary lobes: the frontal, temporal, parietal and occipital lobes. The majority of language‐related activity occurs in the left side of the brain; occasionally a person uses both hemispheres, and even less commonly the right hemisphere only. There are a number of key areas of the brain involved in language function (Figure 5.7):

Broca's area, located in the frontal lobe, is associated with speech production and articulation in written and spoken language.
Wernicke's area, located in the temporal lobe, is primarily involved in the comprehension of language.
The angular gyrus is in close proximity to a number of regions including the parietal, occipital and temporal lobes. It allows people to associate a perceived word with different images, sensations and ideas.

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Figure 5.7 Areas of the brain involved in the communication process. Source: Reproduced from Tortora and Derrickson ([270]) with permission of John Wiley & Sons.

Disorders of communication have a number of causes, for example neurological conditions (e.g. traumatic brain injury, stroke, brain tumour, spinal injury or epilepsy) or progressive neurological disease (e.g. motor neurone or Parkinson's disease). These may result in language disorders, cognitive communication disorders, motor speech disorders, voice difficulties or a combination of difficulties.

The incidence of communication difficulties varies. Speech and language difficulties are more common in childhood but acquired difficulties can occur in adulthood. The Stroke Association ([262]) reports that a third of stroke survivors experience some degree of aphasia. Shafi and Carozza ([253]) found that aphasia occurred in 30–50% of all patients with a brain tumour.

Speech is the primary means of human communication and is essential across the lifespan to engage and interact with others (Etter et al. [94]). Language disorders, such as aphasia, can cause miscommunication, resulting in poor medical care and reduced safety (Blackstone et al. [19]). Further, language disorders can lead to feelings of insecurity and anxiety as well as sleep disturbances and stress (Rodrigues [243]).

Barriers to communication

Everyone experiences barriers to communication at times; however, these can increase when someone is unwell or in a hospital setting. For example:

Medical treatment and interventions (e.g. sedation or receiving oxygen) can interfere with a person's ability and desire to communicate.
Physical difficulties, such as visual or hearing difficulties, can form barriers to communication.
Fatigue can make communication too effortful.
Cognitive impairment, such as memory difficulties, reduced concentration and attention, distractibility and reduced insight, can make communication difficult.
Environmental factors, such as a noisy and busy hospital environment, can place an added burden on a person already struggling with communication.
Cultural differences in social interaction (such as use of eye contact, attitudes about personal space, use of gestures, and accents) vary greatly across cultures.

Evidence‐based approaches

The speech and language therapist (SLT) has a key role in the specialist assessment and management of acquired communication, voice and swallowing disorders. Patients with diseases affecting their central nervous system require input from a multiprofessional team, to support their complex changing care needs throughout the patient pathway (NICE [202]).

Pre‐procedural considerations

Equipment

Communication aids

Communication aids are referred to as augmentative or alternative communication (AAC). AAC may range from basic picture charts or books to electronic aids and computer programmes. AAC helps to compensate for persistent or progressive communication difficulties. AAC can also be useful in the short term for hospital inpatients who are intubated or have an altered airway. AAC intervention approaches can be used to meet daily communication needs to ensure participation and independence in a variety of situations (Hanson and Fager [118]). Box 5.7 provides suggestions to facilitate realistic expectations and successful use of AAC.

Box 5.7

Points to consider when using augmentative or alternative communication (AAC)

There should be an early referral to the speech and language therapist to assess the appropriateness of the use of AAC.
With the addition of any aid (no matter how simple or sophisticated), communication becomes more complex and difficult as it involves another step in the process; that is, it changes from a two‐way to a three‐way process.
Patients need to be motivated to use aids.
The use of aids requires planning, extra concentration and time, listening, watching and interpretation by both the patient and their conversation partner.

Principles of communicating with people with aphasia

Table 5.4 Supporting communication for a person with aphasia

Principle	Rationale
Identify in advance if a patient has impaired attention, concentration and/or memory.	This will affect what you say and how you check for understanding. E
Have a pen and paper ready for both the patient and yourself to use during the conversation.	Writing or drawing can support what is being said. E
Introduce a topic clearly.	If a patient has receptive difficulties, being clear on the subject matter will aid their understanding. E
Allow time for pauses and silences.	To help patients who have delayed processing or who become overwhelmed. E
Say one thing at a time and pause between ‘chunks’ of information.	To allow time for understanding and questions. E
Speech should be clear, slightly slower than usual and of normal volume.	To ensure the patient has time to process what is being said. E
Minimize interruptions.	To aid concentration and engagement. E
Use straightforward language, avoiding jargon.	Medical terminology can involve long words and be complex, which can inhibit understanding. E
Provide visual representations (printed photos and mobile devices).	This will aid the person's understanding and engagement. E
Talk directly to the patient and ask what is and is not helpful.	To ensure communication is as effective as possible. E
Structure questions carefully and make use of closed questions.	To limit the need for complex expression. E
Regularly check the patient's understanding.	To ensure they continue to be involved in the conversation and are respected. E
Be prepared for their and your frustration. You might need to return to a topic another time.	Abilities may fluctuate, so what helps one moment might not work another time. E

Principles of communicating with people with impaired speech (dysarthria)

Dysarthria may range from mild, slightly slurred or imprecise speech to speech that is affected to an extent where the patient is unintelligible (this is different from aphasia, where language is not affected).

Table 5.5 Supporting communication for a person with dysarthria

Principle	Rationale
Find a quiet environment in which to speak.	To reduce distractions and make it easier for the patient to concentrate. E
Have a pen and paper to hand, and encourage writing when necessary.	To provide a quick and easy medium of communication during periods of breakdown. E
Ask if the patient uses any strategies to help their speech.	Patients may be able to use gesture, writing or drawing to help facilitate their communication. E
Encourage a slower rate of speech and regular pauses.	Slowing down rate of speech and ensuring adequate breath support can aid intelligibility for the listener. E
Allow more time than usual.	So the person does not feel rushed and pressured, which can reduce intelligibility. E
Be encouraging but honest and open if you are having difficulty understanding.	This allows the patient to repeat things or express things in another way that may be more understandable to the listener. E

Principles of communicating with people with impaired voice (dysphonia)

The dysphonia may fluctuate from mild voice changes to the patient not being able to give voice at all. All patients with persistent dysphonia may benefit from an early referral to ear, nose and throat specialists followed by a referral to an SLT if appropriate.

Table 5.6 Supporting communication for a person with dysphonia

Principle	Rationale
Face‐to‐face communication is preferable.	The patient will then also be able to use non‐verbal communication (such as facial expression) to transmit their messages. E
Avoid having to talk where there is background noise.	To reduce the necessity for the individual to strain their voice unnecessarily. E
Have pen and paper to hand, and encourage writing when necessary.	To provide another medium of communication during communication breakdown. E
Encourage regular sips of water.	To maintain hydration and keep the throat area moist. E
Encourage the patient to talk gently and avoid shouting or whispering.	To minimize voice strain. E

Principles of communicating with people who are blind or partially sighted

Sight loss varies from mild to complete. For any patient, sight loss is significant, and they will rely more on other senses, especially their hearing. Good communication practice is essential and nurses may need to be the eyes for the patient and relay information they are not aware of – for example, that the patient's visitor has arrived and is waiting. It is important to be open about the visual impairment and identify the person's preferred communication method(s). No single method will suit all people; even the same person might use different methods at different times and under different circumstances.

People who are blind or partially sighted have the same information needs as everyone else and need accessible information in a suitable format, such as large‐print documents, Braille or audio. Access to information facilitates informed decisions and promotes independence. The Royal National Institute of Blind People has useful information on its website (RNIB [241]).

Table 5.7 Supporting communication for a person who is blind or partially sighted

Principle	Rationale
Gain the attention of the person who is blind by speaking first; when you arrive, introduce yourself and state what your role is as well as where you are in the room. Clearly state when you are leaving the room.	Visual cues are diminished or absent to people who are blind or partially sighted, and they may be disorientated in unfamiliar environments (RNIB [240], E).
Turn down or off any unnecessary background noise; use verbal cues and use names to indicate who is speaking to whom, especially in a group setting.	As visual cues are diminished or absent to a person who is blind, their hearing is particularly important for effective communication (RNIB [240], E).
Ask the person whether they would like help before providing it.	It is polite to check (Stevens [258], E).
Use clear and careful explanations and verbally check that the person you are communicating with understands what you are saying.	A substantial essence of meaning is communicated non‐verbally; people who are blind do not receive this information so it may be harder for them to gain full understanding (RNIB [240], E).
Give clear and precise instructions.	A person who is blind or partially sighted, especially in an unfamiliar environment, needs clarity to be able to follow any instructions (Stevens [258], E).
Let people know ahead of time about changes to their environment, for example ground surfaces (slopes, slippery floors), whether a door opens towards or away from them, and stairs.	This enables a person to stay safe (Stevens [258], E).
It is all right to use language such as ‘look’, ‘see’ and ‘read’.	People who are blind or partially sighted have the same vocabulary (Stevens [258], E).
Provide information in accessible ways, for example audio (including recordings of appointments), Braille or large print.	To ensure the communication preferences of people who are blind or partially sighted are followed (RNIB [240], E; Stevens [258], E).
Ensure glasses are clean and within reach.	Some people who are registered blind do have some sight (RNIB [240], E).

Principles of communicating with people who are deaf or hard of hearing

As with blindness, the severity of people's hearing impairments vary. If a hearing aid is used, make sure it is fitted and working. Remember that hearing aids amplify everything, including background noise, which can make communication difficult in busy and noisy waiting areas or departments such as A&E. More severe hearing loss will not benefit from an aid and these patients might rely on lip reading and/or signing or writing.

Table 5.8 Supporting communication for a person who is deaf or hard of hearing

Principle	Rationale
Find a suitable place to talk – somewhere quiet with no noise or distractions – and close doors when possible.	To reduce noises that may be amplified by hearing aids or be distracting or overwhelming (Ludlow et al. [157], R).
Ensure that there is good light and that your face can be seen. Use natural facial expressions and gestures and try to keep your hands away from your face.	Facial expressions and body language can help to contextualize information and facilitate understanding (Ludlow et al. [157], R).
If the person is wearing a hearing aid, ask whether it is on and whether they still need to lip read.	Because at times individuals may turn their hearing aids off because they are not functioning or the interference from background noise is painful. They can then forget to switch the hearing aid on again. E
Ask the person what their preferred mode of communication is.	It is important not to make assumptions about how the person wants to communicate (Burgess [39], E).
If an interpreter is required, always remember to talk directly to the person you are communicating with, not the interpreter.	This is respectful and confirms that it is them you are addressing. E
Sit or stand on the same level as the person.	This makes it easier for them to see your face and lips (Burgess [39], E).
Be patient and allow extra time for the consultation or conversation.	It is likely to take longer than normal. E
Make sure you have the listener's attention before you start to speak.	Otherwise they may miss crucial information (Burgess [39], E).
Contextualize the discussion by giving the topic of conversation first.	Context helps people to understand (Ludlow et al. [157], R).
Talk clearly but not too slowly, and do not exaggerate your lip movements.	Lip reading is easier when the speaker talks fairly normally (Ludlow et al. [157], R). Exaggerated mouth movements can distort lip patterns (Burgess [39], E).
Use plain language; avoid waffling, jargon and unfamiliar abbreviations.	Plain language will be more easily understood. E
Check that the person understands you. Be prepared to repeat or rephrase yourself as many times as necessary.	Many people need to have information repeated to understand it (Ludlow et al. [157], R).
Depending on the purpose of the consultation, writing down a simple summary of the key points might be helpful.	This will ensure the person has a record of what is said in case they have misunderstood or misheard. E